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Hospice Care

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Hospice care for terminally ill animals and their families is showing steady growth in demand and supply, and veterinarians are receiving more requests from clients for this type of support.

Unfortunately, there’s still a lack of veterinary-geared educational resources for hospice care. As the provider of a nationwide volunteer-based, non-veterinary animal hospice helpline for the last five years, I have witnessed the disheartening dichotomy between client expectations (for patient care comparable to human hospice) and the provided or refused veterinary services (once euthanasia suggestions were not accepted by the client).

More of us are following in the inspiring footsteps of pioneer veterinarian Dr. Eric Clough. “In hospice, we never say there’s nothing more we can do,” he stated more than a decade ago. “There’s always something in the way of comfort.” Are you up for it?

Changing our outlook on death
Most veterinarians (including myself) and clients agree with what is said the AVMA Guidelines for Veterinary Hospice Care — that euthanasia may still be required when giving hospice to an animal if he cannot be kept comfortable. Nonetheless, for a public aware of the many benefits of human hospice, it can be difficult to hear veterinarians say that euthanasia alone is the greatest gift they can give terminally ill animal family members.

Those already familiar with the unfolding of an unhurried death also recognize that the quality of life scales some utilize in veterinary medicine, at times even in the name of hospice, are based on non-acceptance of the dying process. Modern hospice is defined by embracing death as “nothing to be feared nor avoided, not to be postponed nor hastened”, while providing for the highest quality of life possible. For practitioners not resonating with this principle, yet offering palliative care to terminally ill patients, the term “end-of-life care” can be used.

In his article “The ethics of influencing clients”, J. M. Yeates suggests that “Withholding options is arguably the strongest form of coercion.” Veterinarians not inclined to assist the dying and their families without euthanasia can still point out all the options to their clients, and refer them as needed. Otherwise, truly informed consent remains elusive, and “hospice” outcomes will yield near 100% euthanasia rates. It does not have to be that way.

The more we know about achieving comfort for the dying, the lower euthanasia rates fall among patients in hospice. On last count, 67% of hospice patients in my holistic practice, while also remaining in the care of their primary conventional veterinarian, died in their own time. The owners were deeply grateful, and prone to re-elect the same option for their other pets. The sooner these owners learned about end-of-life options, the higher the percentage of those who chose to hospice their animals. It rose from zero to 56% once I realized it could be done; clients were much more likely to choose hospice if they knew of the option well before they entered into the distress of their animals being diagnosed as terminally ill.

What to know about offering hospice
• It has to come from your heart. Otherwise, locate and provide referral resources (no shame, no blame!). Being prepared to refer if hospice services cannot be provided is also suggested in the AVMA Guidelines on Veterinary Hospice Care.

• Seek out the best animal hospice education for both veterinarians and technicians. The aim is to be as adept in offering support through the patient’s dying process as you already are in delivering euthanasia.

• Locate team members also outside your practice: in hospice, both the patient and his family receive care! Recommend reliable pet sitters with experience in special needs care for times when the animal’s owner goes to work, travels or needs respite. A social worker can help the caregiver solve daily logistics, while a bereavement counselor can help the family with their grief, including anticipatory grief. An animal chaplain can provide comfort, help the family process spiritual concerns, and deliver memorial services. Family, friends and experienced clients with an interest in volunteering can be engaged in sharing the workload and daily household tasks.

• Inform clients of end-of-life options early, before their animals face a terminal illness.

• Offer house call visits for hospice patients; where state regulations allow, most such visits can be done by a tech under “indirect supervision”. Alternatively, partner with or refer clients to a house call veterinarian.

• Ask for and listen to the caregiver’s beliefs, needs, goals and concerns as much as you pay attention to the animal’s needs. One affects the other, always.

• Educate the caregiver on the animal’s health condition. Whenever a disease progression is discussed, illuminate available comfort care measures. Keep in mind that an invasive procedure can at times provide the most effective and suitable comfort care – for example, a thoracocentesis to relieve respiratory distress, or using an esophageal tube when an animal, though still hungry, can no longer eat on his own due to a mouth tumor. Just remember that force feeding an animal that has lost his appetite is contraindicated in hospice care.

• The caregiver’s perspectives, capabilities and circumstances are taken into consideration when shaping the treatment plan. Constant pain needs constant treatment — prn dosing is unsuitable for those situations, and pain levels should not be allowed to spike. Demonstrate palliative care techniques to owners; often, this can be done by a technician.

• Encourage the caregiver to keep a daily health log to track the animal’s current situation and any changes as well as treatments. This will help with care evaluation, allow others to smoothly take over the care on a temporary basis, and aid in distinguishing medication side effects from disease progression.

• Include lower budget options. Consider effective solutions that are easily available to the average household, such as pumpkin and rectal hydration for constipation. Another example are heat packs and cold packs, which can be remarkable pain relievers where indicated. Or empower “hands on” inclined clients by teaching them simple acupressure techniques helpful to their animals.

• Always equip hospice clients with comfort kits for their animals in case a crisis arises outside business hours. The kit should contain medications to be kept in the patient’s home in the event of emergency. It contributes to peace of mind for the caregiver — and for you even if none of the contents have to be used. A comfort kit may save the day — or the night, if an emergency arises when veterinary help is not within immediate reach.

• The hospice kit should contain a strong fast-acting pain medication such as morphine. Also include an anxiolytic (consider lorazepam, as it can be safer than diazepam in medically fragile animals), and any medication that may be required if the patient’s particular condition suddenly progresses.

• If you are already practicing integrative medicine, you may be able to offer patients homeopathics and/or herbs or essential oils that may alleviate symptoms without the use of conventional medications. However, the latter should always remain a part of the comfort kit.

• Even if you momentarily think it, don’t say: “Nothing else can be done to make your animal (more) comfortable,” just because you are stepping into unfamiliar territory. If pain is the issue, consider multimodal approaches. Make sure to know how to treat neuropathic pain. If all available knowledge and experience fail, approach the situation with a “beginner’s mind”. Relax to allow the solution to come to you. It may be a lot simpler than you can imagine.

• Aim to provide 24/7 access to advice. Trained techs on rotation, other hospitals, or house call vets may partner with you. Consider special agreements with emergency clinics, or a local pet hospice team, if available. If all else fails, simply limit the number of patients you accept for hospice service. Your health comes first!

• Always arrange for 24/7 access to in-home euthanasia in case it’s needed. Here too, rotating those on call is key. Generally, hospice patients are only euthanized if their comfort levels cannot be sufficiently maintained despite best available palliative care.

• As needed, provide emotional support for the family after the death of their animal companion (this also applies in non-hospice end-of-life care).

• Take good care of yourself, whether you decide to engage in hospice or not! Embrace death and celebrate life!

• Don’t let a lack of experience keep you from considering hospice care. A willingness to serve and search for solutions can often counterweigh limited experience as long as there is clear communication with clients. As we allow ourselves to delve into delivering support beyond where we have gone before, we may start seeing with the eyes of one of my Spirits in Transition seminar participants, who wrote: “Slowly, one by one, a shift is beginning. I do many ‘things’ but this hospice is my crusade. Working in a very Western-minded veterinary clinic, it does continue to be quite challenging. But any chance I get, I offer the option to consider hospice — guiding [clients] along the path, helping however I can, until the time when, the needle ‘robbed’ of its task, the spirit departs, and I can look into the eyes of one who has just lost a very beloved companion and see, not raw grief, but a sense of wonder and peace…. It is so worth it!”


References
Armer, J., Bittel, E. “When is end-of-life care for animals truly hospice? The (almost) invisible difference determining life and death”, The Latham Letter, Fall 2011. American Veterinary Medical Association (AVMA), Guidelines for Veterinary Hospice Care, update April 2011. Clough, E. and J. “Helping clients say good-bye — hospice for pets”, AVMA conference proceedings, 1997. De Louise, D., Lane, M. S. “Pet hospice — caring until the end”, ASPCA Animal Watch, 2001. NHPCO Facts and figures: Hospice care in America, National Hospice and Palliative Care Organization, 2010. SpiritsInTransition.org (animal hospice helpline and communications), 2006 to present. Tremayne, J. “Focusing on the end”, Veterinary Practice News, July 2008. Yeates, J. M. “The ethics of influencing clients”, J Am Vet Med Assoc, 237(3), 263-7, 2010. [callouts] Hospice is defined by embracing death as “nothing to be feared nor avoided, not to be postponed nor hastened”, while providing for the highest quality of life possible. 67% of hospice patients in my holistic practice, while also remaining under the care of their primary conventional veterinarians, died in their own time. The owners were deeply grateful, and prone to re-elect the same option for their other pets. Dr. Ella Bittel graduated from veterinary school in Hannover, Germany, in 1994. Specializing in holistic modalities, she studied homeopathy in her home country, certified with the American Veterinary Chiropractic Association (AVCA) in 1998 and the International Veterinary Acupuncture Society (IVAS) in 1999. Now living and working in California and Arizona, Dr. Bittel also offers craniosacral work and herbal approaches. She presents on integrative animal hospice care at veterinary conferences and the International Symposium for Veterinary Hospice Care, and is on the advisory board for the Nikki Hospice Foundation for Pets (NHFP). Being aware of the lack of educational resources in the area of her greatest passion, Dr. Bittel has also created weekend seminars and online classes on animal hospice care (spiritsintransition.org).